Poor health is high on political agendas (Krech, 2011) and insufficient physical activity is a major risk factor for obesity, type-2 diabetes, heart disease and some cancers (Hallal et al., 2012b; Lear et al., 2017). Across the globe, physical inactivity is recognised as a major determinant of chronic conditions (World Health Organization, 2014b). Research suggests there is an urgent need for global action to address physical inactivity as a public health priority (Kohl 3rd et al., 2012).
Extensive evidence is published on the numerous physical and psychological benefits of physical activity across the human lifespan (Tucker and Carr, 2016; Lear et al., 2017). Australia, like other developed countries, has very low levels of physical activity (Australian Bureau of Statistics, 2012). Tasmania has the lowest levels in the country, with 69.4% reporting inadequate levels of physical activity participation in comparison to Australia which is 67.5% (Population Health, 2013). Australian Physical Activity Guidelines
recommend at least 30 minutes of moderate physical activity for adults on at least five days of the week, equating to 150 minutes a week (Australian Department of Health, 2014). Thus developing effective interventions to increase population physical activity levels is
undoubtedly important to the health of Tasmanians. Best practice research recommends a multi-strategy approach is most effective to increase population-level physical activity levels; however, there is little evidence of successful initiatives in peer reviewed literature due to the complexities of effectively measuring multi-strategy community-wide projects (Deakin University, 2012). Therefore, the purpose of this study was to use an interrupted time-series process and impact mixed-methods research design in an attempt to effectively measure the
efficacy of a multi-strategy community-wide physical activity intervention in the Tasmanian regional community of Launceston.
The mixed-method process and impact evaluation of Active Launceston allowed for the triangulation of data. This methodology, including the collection of both qualitative and quantitative data, appears to be a unique aspect of Active Launceston when comparing it to other community-wide multi-strategy physical activity projects in the literature and a key aspect of our five pillar model. This triangulation of data provides evidence for the perceived positive impact on individuals, as observed by individuals themselves and key stakeholders such as program instructors, theoretically leading to community-wide benefit, relevant to the health-promotion sector. As presented in the literature review, Fortmann (1995) reiterates this by suggesting that community-wide effects are better reported through detailed process evaluation with a reduced focus on traditional expensive outcome-based quantitative evaluation. Mummery and Brown (2016) take the concept further to suggest more
comprehensive process measures allow for a greater insight into the reach of strategies and make it possible to conduct analysis of the contributions of strategies to community-wide behaviour change.
We have shown qualitatively that Active Launceston impacted profoundly on individuals and resulted in significant changes in their level of physical activity, aiding improvements in physical and mental health and levels of social engagement. Quantitatively, results
demonstrate that participation levels in walking remained constant over the years, while the proportion of people participating in moderate physical activity gradually declined. In contrast, levels of participation in vigorous physical activity were found to be significantly greater in 2012 and 2015 compared to 2008. The difference in vigorous physical activity observed between 2012 and 2015 (Figure 3) can be attributed to a higher proportion of
respondents aged over 45 years in 2015. Sufficient activity for health as defined in the current study represents a combination of these three physical activity intensity levels. Although there is a significant decrease in moderate physical activity levels, and despite an older cohort of respondents in 2015, a statistically significant increase in the number of people engaging in sufficient physical activity for health was observed. In isolation, these changes cannot be directly attributed to Active Launceston; however, when combined with the significant differences observed in 2012 and 2015, where those who were aware of Active Launceston were more likely to be sufficiently active for health than those who were unaware of Active Launceston, a plausible relationship can be proposed. There was also an encouraging positive trend observed for those who had participated in an Active Launceston program and were sufficiently activity for health, further strengthening this assertion. Future longitudinal and comparative research is required to confirm a causal relationship.
Interventions to increase physical activity levels are common; however, much of the research has focused on the impact of structured programs that target small groups of individuals with specific illness (Bazzano et al., 2009; ). Few examples exist of community-wide programs that use multi-strategy and wide-scale approaches to promote physical activity (Deakin University, 2012). This is likely to be due to the complexities of implementing community- wide initiatives (Brown et al., 2003; O'Hara et al., 2012). However, the value of
implementing physical activity programs for specific populations has been established. For instance, a targeted initiative designed to reduce childhood obesity has been successful in demonstrating the value of ‘a multi‐strategy, multi‐setting community development approach’ (Pettman et al., 2010). Peterson et al. (2008) demonstrated that adults with development disabilities can improve their lifestyles through a community-based program. Pardo et al. (2018)demonstrate that participating in regular physical activity produces multiple benefits for adolescents in Spain.A community-based project targeting women
demonstrated that developing a program for a specific population can succeed in increasing physical activity participation (Wen et al., 2002). These studies, provided as an example of many, demonstrate that strategies to increase physical activity are apparent, but the effect sizes are often small and thus the strategies are not widely adopted (Bauman et al., 2012). Therefore, the benefit of community-wide multi-strategy interventions such as Active Launceston is evident.
Through community engagement, Active Launceston adopted a multi-strategy approach at the population level to increase physical activity, and success is reflected in the program’s high numbers of participant and session attendance (n = 30,342 in comparison to Pawtucket for example n = 10,051) and broad levels of engagement. This approach aligns with Eaton and colleagues’ (1999) research that highlights the importance of population-based
interventions, suggesting that a wide range of individuals should be involved to increase population physical activity levels. Sallis and Bauman (1998) also argue that ‘population- wide interventions are needed’ to reduce the burden of ill health, but that policy and environmental interventions will carry the most weight when attempting to change a
community’s behaviour. This ecological approach (Golden et al., 2015; Richard et al., 2011) resonates with the Active Launceston framework, which works in partnership with local and state governments, and aims to influence policy and environmental interventions while promoting the benefit back to the community.
Adopting multiple strategies to promote the benefits of physical activity and engage
communities in higher rates of participation is seen to be optimal by researchers (Baker et al., 2015). Active Launceston used multiple strategies across five key pillars: supportive
environments, mass media, community initiatives, professional support and multifaceted evaluation. Process evaluation demonstrated that these multiple strategies enabled the Active
Launceston health promotion initiative to achieve brand and service recognition and reverence across the community and across demographic cohorts evidenced in program recruitment and retention. To achieve these outcomes, Active Launceston was underpinned by the Ottawa Charter of health promotion (World Health Organization, 2014a).
The Ottawa Charter defines health promotion as “the process of enabling people to increase control over, and to improve, their health” (World Health Organization, 2014a). Within the university sector, the Okanagan Charter for Health Promoting Universities, suggests that responsibility should be accepted by higher education institutions for their potential influence and leadership role in improving societal health and wellbeing, through collaborations, networking and community engagement (University of British Columbia, 2015). In an interview in November 2012, David Rich, Provost, University of Tasmania, suggested that, together with research and teaching, university–community engagement has emerged as one of the key elements of university core business. It has evolved to a point where it is no longer regarded as something that is separate from, or an add-on to, other core interests, but is integral to all the operations of the university.
Engagement Australia (2014) defines engagement as:
“the cultivation of relationships that lead to productive partnerships which yield mutually beneficial outcomes to universities and their partners through the application and utilisation of university resources including staff, students, infrastructure and knowledge and across the breadth of university activities including research, education and service.”
Our qualitative research shows that the Active Launceston partnership, managed by the University of Tasmania, leveraged resources through a level of ownership from the community and its leaders, resulting in the successful engagement of target audiences,
including those from disadvantaged backgrounds who are traditionally difficult to engage (Farrell et al., 2014; Werneck et al., 2018).
Elements that affect why some people are active and others are not can be categorised as: intrapersonal, interpersonal, environmental, regional, national and global. These factors may work alone or together and impact one’s ability and/or willingness to participate in physical activity (Macera and Ainsworth, 2012). Low socio-economic status is one of these elements that has a negative relationship with physical activity participation (Macera and Ainsworth, 2012). Based on the 2011 ABS Census, the socio-economic indexes for areas (SEIFA) ranking for Tasmania is 961 (Australian Bureau of Statistics, 2013). Comparing on a national level, this is considered an area of relatively greater disadvantage. A recent study shows the gap between physical activity participation in the disadvantaged and the advantaged
populations has increased, so the need for intensive interventions for these subgroups is warranted (Bauman et al., 2012). Approximately 43% of Active Launceston participants resided in suburbs that are among the state’s five lowest deciles of SEIFA, with 19.3% in the lowest decile, thereby addressing this gap.
The evaluation findings of Active Launceston support claims that health-promoting interventions that are community-focused have the potential not only to target behavioural risk factors for disease, but also to improve health outcomes by contributing to social capital of the community. Hawe and Shiell (2000) provide a commentary on the relationship
between social capital and health promotion, and attempt to understand how communities, environments and relationships can improve health and wellbeing. They identify the
following as being crucial to successfully harnessing social capital: careful interpretation of power and empowerment, building relational ties, capacity-building of communities and individuals, and creating healthy public places and policies. Qualitatively, we have identified
the potential of Active Launceston to contribute to this objective by empowering participants to make changes to their lifestyle, building relationships with other community members around the shared goal of increasing physical activity, and supporting the broader physical activity industry. The findings appear to be unique to the current study, which has found a positive relationship between the development of social capital and a community-wide multi- strategy physical activity project. However, it is recognised there is still more work to be done, as there remain many people who are not engaged in sufficient physical activity in the Launceston community.
It is apparent that there is a hiatus between the research on physical activity interventions and the ‘real life’ delivery of evidence-based initiatives in practice (Bazzano et al., 2009).
Mittelmark and colleagues (1993) discuss a plethora of problems with collecting data over time, such as changing secular trends, migration patterns, and changes in resourcing. They therefore suggest that it can be a trap to pay too much attention to the material aspects of an intervention. They emphasise the need for service-oriented (as opposed to research-oriented) programs and to be realistic in how the data that is collected is emphasised in the literature. Mittlemark et al. (1993) recommend using participation rates as a primary outcome measure, and they also suggest that process evaluation is at least, if not more, important than assessing risk factor change. Mummery and Brown (2016) in their paper entitled ‘Whole of community physical activity interventions: easier said than done’ conclude that whole-of community interventions are a big challenge for academics but they still hold huge potential to make population-level changes to physical activity. They suggest that researchers need to
understand more about the usefulness of individual strategies, how to engage marginalised groups, effectiveness of community groups and the basic mechanisms of community engagement. The Stanford Five City Project and the MHHP provide an example of these difficulties, as both were deemed to be ineffective by researchers; however, it should be
recognised that they reported only incidence and prevalence data (objective measures), but did not measure other important elements of physical activity projects such as social
outcomes including social capital. Mummery and Brown (2016) site this as a ‘flaw’ in other whole-of-community projects, as a lack of process information does not allow for an analysis into the strategies implemented to effect behaviour change nor the social outcomes they create. Qualitative results from this study demonstrate that Active Launceston did measure social outcomes and, coupled with quantitative data, the findings suggest Active Launceston supported a wide range of individuals to engage in regular physical activity, and increase their level of social engagement. Quantitative results of Active Launceston also demonstrate a significant increase in those who are sufficiently active for health, and a positive
relationship between those who were aware of Active Launceston and those who were sufficiently active for health. As outlined above and as demonstrated in our Five Pillars model, this level of analysis appears to be unique to the current study when comparing to other community-wide case studies presented; it provides an important understanding of one of the elements that contribute to population-level behaviour change. Given the results of the process and impact evaluation of Active Launceston, with continuation of the program, the next phase in the evaluation of the efficacy of this type of multi-strategy community-wide intervention is to assess outcome measures including: morbidity and mortality statistics, hospitalisations and healthcare costs. It is acknowledged that the current research design will need be altered to successfully measure these outcomes.
Limitations
As discussed above, measuring and interpreting outcomes at a community level is challenging, and inherent limitations apply to this evaluation of Active Launceston. This thesis’ contribution is an evaluation that shares the difficulties of reliably measuring and interpreting outcomes in an uncontrolled environment (Deakin University, 2012; World
Health Organization, 2001; Sanson-Fisher et al., 1996). As per all non-observatory research, there is the potential for self-report bias (Prince et al., 2008) and bias due to declining survey response rates (Brick and Williams, 2013). The lack of a controlled environment and no parallel control group make attributing a causal relationship between the initiative and the population survey results challenging (Baker et al., 2015). Data collected in this study is non- comparable to Tasmanian state level data due to the Tasmanian Health Survey adopting questions from the Victorian Health Survey rather than questions from the Australian Exercise Recreation and Sport Survey (Australian Sports Commission, 2008) which is utilised across all other Australian states and territories.
It must be noted, that with limited resources and an understanding that allocating funding directly to the intervention community would result in a higher impact on behaviour change (Fortmann et al., 1995) rather than diluting the reach and impact by spreading the funding across both a control and an intervention community (where cofounding uncontrollable variables would still exist and influence validity), Active Launceston learnt from the failings of other community-wide interventions, such as the Stanford Five Cities and MHHP, by controlling this element of the study design (Fortmann et al., 1995).